Page 9 - 2016 Enrollment

Vision Coverage

Voluntary Vision Benefit Summary

VSP
Network: VSP Signature

In-Network Out-of-Network
Reimbursement Level
Eye exam $10 copay Up to $50
Lenses
Single $25 copay Up to $50
Bifocal $25 copay Up to $75
Trifocal $25 copay Up to $100
Lenticular $25 copay Up to $125
Frames $150 allowance, $170 for featured frame Up to $70
brands; 20% off balance over allowance
Elective contacts in lieu $150 allowance and up to $60 copay for Up to $105
of glasses itting and evaluation
Medically necessary
contact lenses Covered at 100% Up to $210
Frequency
Exam, lenses, or
contacts 12 months
Frames 12 months

Notes: this is a synopsis of coverage only; the beneits summary contains exclusions and limitations which are
not shown here. Please refer to the beneits summary for the full scope of coverage.

The vision plan is offered through Vision Service Plan (VSP). The vision plan covers

routine eye exams and also pays for all or a portion of the cost of glasses or contact
lenses if you need them. Please note the dependent eligibility on the vision plan is
age 19 or 25, if a full-time student.

In the vision plan, you can receive services or materials from an in-network or an
out-of-network vision provider. If you go to an in-network provider, you will only
pay the amounts listed in the in-network column. If you go out-of-network, you
will be reimbursed up to a speciic level, depending on what service or material
was provided. To locate an in-network provider visit www.vsp.com and select the
Signature Network or call 800.877.7195.

9